Health & Science

Baylor St. Luke’s Identifies Practices In Need Of ‘Immediate Attention’ Ahead Of Federal Inspection

Results of the upcoming inspection could determine if the hospital keeps federal funding.

Baylor St. Luke’s Medical Center is preparing for a full site inspection by federal regulators, News 88.7 has learned.

A January inspection found the hospital out of compliance on three of the Centers for Medicare & Medicaid Services’ (CMS) requirements: patient rights, quality assurance and performance improvement, and nursing services. Findings from that inspection triggered CMS to order a full unannounced survey of the hospital within 60 days to be carried out by state health officials, a CMS spokesperson said. This will be the first full survey of St. Luke’s since April 2018.

A letter sent to physicians by Chief of Staff William Granberry and obtained by News 88.7, details practices in need of “immediate attention” before inspectors arrive.

Verbal orders are not acceptable except in emergencies, Granberry noted. He added that all handwritten orders must be dated and timed, and pre-signed order sets will no longer be accepted. He instructed staff not to make any documentation using a medical provider’s log-in.

Granberry also reminded staff of proper hand washing and sanitizing procedures, not to take food into patient areas, and of when to change scrubs, face masks and shoe covers. Included in his note were reminders of universal protocols such as marking surgical sites on patients, using two patient identifiers and performing a “time out” to ensure everything is correct prior to surgery.

“Baylor St. Luke’s leadership has already mobilized multi-disciplinary teams of physicians, nurses and staff – guided by outside experts from across the country – to evaluate every key aspect of our operations and identify immediate steps we need to take for patient care,” Baylor St. Luke’s Vice President of Quality Megan Fischer said in a statement released to News 88.7.

The CMS notification of the upcoming inspection does not affect Baylor St. Luke’s status for Medicare or Medicaid reimbursement, or affect ongoing hospital operations, the hospital said.

T. Douglas Lawson was named president of Baylor St. Luke’s Medical Center following the departure of former president Gay Nord.

St. Luke’s lost federal funding to its heart transplant program last year following a Houston Chronicle and ProPublica investigation into surgical complications at the hospital. Later investigations by the papers revealed problems within the hospital’s lung and liver transplant programs.

The hospital has since removed its president and two administrators and hired three new executives as it tries to address problems with its transplant programs and nursing practices.

View a copy of the letter below:


Davis Land

Senior Producer

Davis Land is a senior producer at Houston Public Media. He cut his teeth at Atlantic Public Media in Woods Hole, MA and at WBUR in Boston. His work has appeared on various public radio programs and podcasts including Texas Standard, Here and Now, and Marketplace. Davis is a graduate...

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